ANESTHETIC MANAGEMENT OF A NEWBORN WITH A

CERVICAL MENINGOMYELOCELE
S. Parthasarathy*, A. Umeshkumar**, Sameer Mahamud
Jahagirdar*** and M. Ravishankar****

Abstract
Anesthesia of a newborn poses different types of challenges to the anesthesiologist. Cervical
meningomyelocele adds to the difficulty with positioning and airway problems. We report a case
of successful management of such a case.
Keywords: neonate, cervical myelocele, anesthesia.

Introduction
Myelomeningocele (MMC) a complex congenital spinal anomaly, results from neural
tube defect during first 4 weeks of gestation. Cervical meningocele is an extremely uncommon
congenital spinal anomaly and the incidence is 3- 5 % among spina bifida cystic1. Usually children
don’t present with the neurological manifestations at birth but the surgical exploration is warranted
to prevent the future neurological deterioration2. In this report, we present a neonate with the lower
cervical meningocele which was successfully surgically treated.

Case Report
A term female baby weighing 3.07 kg was born at 40+4 weeks of pregnancy to a healthy primi
mother of nonconsanguineous marriage for an indication of fetal distress and thick meconium
stained liquor by emergency caesarean section. Immediately after birth, the child cried vigorously
with the Apgar score of 8/10 and 9/10 in the 1st and 5th minute respectively. Vitals were stable and
the systemic examination was also normal. Head circumference was 33cm and the baby moved
all four limbs normally. Baby was kept in neonatal intensive care in view of a neck swelling and
the thick meconium stained liquor. Regarding the past medical history, mother consumed folic
acid tablets regularly from 2nd month of conception. Her antenatal ultrasound at the 7th month of
pregnancy revealed a swelling in the neck. Subsequent ultrasound confirmed the same. No history
of any teratogenic drug consumption during the pregnancy and no similar complaints in the family.
In the NICU, baby was started oral feeds and she tolerated well. A single soft fluctuant swelling
5X5cms at summit over midline back over lower cervical region with a skin deficient thin membrane
was noted. The ultra sonogram confirmed the lesion as Occipital myelomeningocele lesion with
mildly dilated lateral ventricles. There were no other obvious anomalies. The surgeons decided

* Department of anesthesiology, Mahatma Gandhi Medical College and research institute, Puduchery, South India.
* Consultant anesthesiologist.
** Postgraduate student.
*** Assistant professor.
**** Professor and HOD.
Corresponding Author: Dr. S. Parthasarathy, Dept. of anesthesiology Mahatma Gandhi Medical college and research
institute, Puduchery, South India. E-mail: painfreepartha@gmail.com, Phone: 09344304042.

735 M.E.J. ANESTH 21 (5), 2012

Discussion
Anesthesia in prone paediatric patients,
to excise and repair the cervical myelomeningocele. especially in neonates poses the highest risk of
Baby was kept NPO for 6 hours on the day of complications. Safe anesthetic management depends
surgery and maintenance fluids were maintained at on complete appreciation of the physiological,
the rate of 12 ml/hr. On the day of surgery baby was anatomic and pharmacological characteristics of
brought to the operating room (OR) and placed on the neonates. As spinal surgery is a major surgery in
the OR table with a warmer under the baby Spo2, children, preoperative considerations has to be done in
ECG, NIBP, rectal temperature, capnography were a vigilant approach3. The child should be evaluated for
the monitors used.12ml/hour of 1/5 of RL (100ml of the associated abnormalities such as VACTERL. Early
5%dextrose with 400ml of RL) was infused through closure of the meningocele and myelocele, typically
the 50ml syringe. The patient’s baseline values were within the first day of life is recommended to reduce
HR=140/min, Spo2=100% with a BP of around 70/50 the bacterial contamination of the exposed spinal cord
which was measured with an appropriate sized cuff.. and subsequent sepsis, which is the most common
Injection atropine 60 µg and fentanyl 6 µg were given cause of death in this population during the newborn
intravenously. Intubation with size 3.0 tracheal tube period4.
was done after inhalational induction with sevoflurane. Intubation and mechanical ventilation is generally
To get the ideal supine position, gauze bandages were considered for all the spinal surgeries. Induction can
kept below the chest and abdomen to compensate for the be done either intravenous or by inhalational4. We
swelling in the back of neck (see fig. 1).This mimicked preferred inhalational intubation. We intubated the
a normal supine neonate. Atracurium 1mg was the non newborn in the supine position and switched over to
depolarizer used. After proper careful precautions, the the prone position for the procedure. To compensate
patient was switched to prone position. Dystrophic for the cervical swelling during the supine positioning,
meninges were excised and transfixed followed by a gauze bandages were kept below the abdomen and
water tight dural closure.. The recovery was smooth chest which gave us an optimal supine position for
with all four limbs moving. Blood loss during the intubation. Preferred muscle relaxant is usually a non
procedure was very minimal (5 ml).The procedure depolarizing muscle relaxant. Atracurium was used
lasted for 90 minutes and throughout the intraoperative being the ideal one in neonates. Meticulous attention
period baby’s vitals were stable. Baby was then shifted should be given while placing the child in prone
to NICU for further monitoring. Postoperatively baby position to avoid life threatening complications5. Prone
was moving all four limbs and vitals were stable with position was carefully given to reduce intra-abdominal
a good cry and normal feeds. pressure and pressure on eyes. Routine monitoring
ANESTHETIC MANAGEMENT OF A NEWBORN WITH A CERVICAL MENINGOMYELOCELE 737

during the surgery were done in our patient. Children basics in maintenance of temperature, oxygenation and
are more susceptible to hypothermia because of little fluid therapy.
subcutaneous fat, and greater surface area to body
mass ratio which makes them vulnerable to apnea,
Conclusion
bradycardia, hypotension, and acidosis6. Hypothermia
also prolongs recovery from neuromuscular block, Neonates are prone for anesthetic complications.
impairs platelet function, and leads to a higher Safe and better management can be provided by
incidence of wound infections. We used warming fully understanding the age related pathophysiology
mattresses, hot air warming blankets and warmed while planning the anesthetic technique. Anesthetic
intravenous fluids to avoid hypothermia7. Blood was management should focus on the positioning, fluid
reserved preoperatively but not used. Postoperative management and maintenance of temperature. The
care was provided with local anesthetic infiltration case is presented for its rarity and its successful
around the wound and IV paracetamol. Our case was management.
different in our airway technique, strict adherence to

References
1. Kasliwal MK, Dwarakanath S, Mahapatra AK: Cervical meningo surgical patients. Neurosurg Clin N Am; 1998, 9:181-5.
myelocele - an institutional experience, Child’s Nervous System. 5. Soundararajan N, Cunliffe M: Anesthesia for spinal surgery in
Volume 23, Number 11, 1291-1293. children. British Journal of Anesthesia; 2007, 99(1):86-94.
2. Fisher RG, Uihlein A, Keith HM: Spina bifida and cranium bifidum: 6. Lee B, Wheeler T: Emergence and recovery from anesthesia for
study of 530 cases. Mayo Clin Proc; 1952; 27:33-8. pediatrics patients in the post-anesthesia care unit. Pediatr Ann;
3. Doran PA, Guthkelch AN: Studies in spina bifida cystica. I. General 1997, 26:461-9.
survey and reassessment of the problem. J Neurol Neurosurg 7. Mural I, Berniere J, Constant I: Evaluation of the efficacy of a
Psychiatry; 1961, 24:331-45. forced-air warmer (Bair Hugger) during spinal surgery in children. J
4. Conran AM, Kahana M: Anesthetic considerations in neonatal Clin Anesth; 1994, 6:425-9.

M.E.J. ANESTH 21 (5), 2012